A Medical Mission to China

MR. ARMSTRONG:

Monsieur le Consul General, invites d'honneur, Mesdames et Messieurs, le Club de l'Empire du Canada est fier de souhaiter la bienvenue pour la deuxieme fois au Docteur Gustave Gingras, une autorite medicale qui est celebre partout, renomme dans le domaine de la rehabilitation et de l'education.

Docteur Gingras, c'est extremement gentil de vous de venir nous parler encore une fois. Nous attendons avec beaucoup d'interet et de curiosite d'entendre parler de votre voyage en Chine.

With grave concern as to the comprehensibility of the foregoing, may I revert to the other of our two official languages and give you a few highlights of one of the great Canadians of our time, Dr. Gustave Gingras, who previously addressed this Club on March 5, 1970.

Our speaker is a native of Montreal, and on completing his medical course at the University of Montreal in 1943 and obtaining the degree of Medical Doctor, he enlisted in the Canadian Army Medical Corps and served both in Canada and overseas from 1943 to 1945.

His professional and academic titles are too numerous to mention. Suffice it to say that he holds certification in Physical Medicine and Rehabilitation in the Royal College of Physicians and Surgeons of Canada and is a Fellow thereof. He has been Executive Director since its founding in 1949 of the Rehabilitation Institute of Montreal, and is Professor of Physical Medicine and Rehabilitation and Director of the School of Rehabilitation at the University of Montreal.

He is immediate Past President of the Canadian Medical Association and the many important positions he has held, his membership on numerous scientific committees and in scientific societies make too long a list for this introduction. Dr. Gingras was made a Companion of the Order of Canada, and was the recipient of the Royal Bank of Canada Award in 1972.

The Rehabilitation Institute of Montreal, which had its beginning in a converted poolroom of an old hotel, was transferred into a modern multimillion dollar building in 1962. It was most propitious that the opening took place when the tranquilizing drug, thalidomide, was causing 5,000 babies to be born with tragic deformities, mainly affecting the arms. Dr. Gingras undertook the care of 43 of the 115 thalidomide infants born in Canada. Two years later in his search for more effective mechanical prosthesis, he learned of a Russian invention which used myoelectricity to control a motorized plastic hand. He flew to Moscow and bid $30,000 for the Canadian patent rights, and later had it developed by Canadian engineers into the world's first completely electromechanical arm. Called the "Canadian Arm" it has been used successfully by both children and adult amputees.

His many special missions under the United Nations Technical Assistance Administration and under the Canadian International Development Agency, the latter mainly to Viet Nam and the former to all parts of the world, have culminated in his leadership, in April and May of 1973, of the first official Canadian Medical Delegation to China.

During the Chinese mission, Dr. Gingras, who enjoys a good cigar, was known as "the illustrious leader of the delegation", just as Chairman Mao is to the Chinese People. At one meeting, attended by several cigarette chain-smoking Chinese, Dr. Gingras discussed the reduced health hazard related to cigar smoking as opposed to cigarette smoking and philosophised on the superiority of the cigar connoisseur versus the cigarette smoker. Mr. Le Tsung-min, Chinese Foreign Ministry official who served as Secretary to the Chinese delegation that visited Canada last November, offered the information that "Chairman Mao occasionally smokes cigars", to which Dr. Gingras replied, "Now I know how he became Chairman."

This giant among his colleagues in rehabilitation medicine throughout the world radiates hope to myriads of disabled people. This humble statement made in the acceptance of one of his many awards best describes the man. "I owe this great honour to my country, Canada. I'll never be thankful enough for what it has done in helping me to carry out my work for the handicapped."

I am honoured to present to this audience Dr. Gustave Gingras who will speak to us on the subject, "A Medical Mission to China".

Dr. Gingras.

DR. GINGRAS:

It is a singular honour to be invited to address this prestigious club twice in just under four years. I am grateful to the President and members of The Empire Club of Canada for giving me the opportunity of bringing to you today what I consider to be an important message.

During April and May of this year, I had the privilege of visiting the People's Republic of China with fifteen of my colleagues from across Canada. We were privileged, in a fifteen-day period, to see a broad cross-section of medical care in the most populous country of the world. As an individual who has been privileged to do a considerable amount of travelling on this planet and who has seen medical care on several continents, I assure you it was a most interesting experience. It was indeed the trip of a lifetime.

Contrary to the comment of a number of radio and television personalities, the delegation of Canadian physicians to China was not brain-washed or hood-winked by a well programmed propaganda tour. As physicians we did witness a number of things that were truly outstanding, surprising, and a clear indication of the ability of our colleagues in the People's Republic of China to provide very high quality medical care. At the same time, we also saw a great deal of medical care that was average, and some that was below our Canadian standards.

The delegation, organized by the Canadian Medical Association, with representation from both the Department of National Health and Welfare and the Medical Research Council of Canada, had three basic goals:

1. To improve the relationships between the health workers of the two countries.
2. To see at first-hand a broad cross-section of health care delivery in China.
3. To initiate negotiations for the long-term exchange of medical scientists and teachers.

All three objectives were realized.

We were extremely pleased with the intinerary organized on our behalf by our Chinese hosts: the People's Republic of China Department of Public Health, their Academy of Medical Sciences and the China Medical Association. During the fifteen days that we spent in Peking, Shanghai, Shih-Chia Chuang, Hangchow, Canton, and the areas surrounding these major cities, our hosts showed us everything that we had requested and answered our questions with a frankness that astonished seasoned observers in that country.

We were provided with the opportunity of visiting medical schools-western medical schools, or medical schools as we know them, and traditional Chinese medical schools. We also had the opportunity to visit major research institutes such as the Shanghai Institute of Physiology where the Chinese are conducting a crash research programme to determine how acupuncture analgesia works. We saw hospitals of small, medium, and large size. We saw community hospitals, state hospitals, mental hospitals, teaching hospitals, medical clinics in factories and on farm communes. We had a very busy fifteen days.

With respect to long-term personnel exchange, that we considered essential and a major aim of the tour, everyone we spoke to, from Dr. Kuo Mo-jo, the Vice Chairman of the Standing Committee of the People's Congress-(the number three political figure in China), to the responsible member or Minister of Public Health, to individual physicians or researchers-all were in complete agreement if not enthusiastic. As it was reported in the public press, I believe, we will see young Canadian medical scientists and teachers studying and teaching in China, and vice versa in the very near future. Chinese medical authorities are anxious to learn of our methods, especially in the fields of heart disease, cancer control, general surgery and hospital administration.

Let there be no doubt that the development of surgical techniques in China to rejoin severed limbs will be of major interest to Canadian surgeons. I confess to you, as a student of rehabilitation medicine for many years, I was astounded to see patients with limbs that functioned extremely well, limbs that had been severed from the individual's body for up to 36 hours. I tested the function of patients who had arms rejoined, at both the upper and lower level, and I assure you that they had excellent function.

Obviously, our teachings that indicate it is necessary to have such severed limbs reconnected within 6 to 8 hours, in order to retain a functioning limb, are inaccurate.

To deal with acupuncture, may I provide a little basic information regarding traditional Chinese medicine-the art that gave birth to acupunture-and treat the subject in two parts. First, to deal with acupunture analgesia and secondly, deal with the use of acupuncture as a therapy modality.

Traditional Chinese medicine is almost completely empirical-there is very little in the way of scientific evidence or fact to support the teachings or activities of traditional Chinese physicians. But the Chinese are currently giving very high priority to the scientific investigation of traditional Chinese medicine. They are subjecting the drugs and the practices of traditional Chinese medicine to scientific review, on a systematic basis.

With respect to acupuncture analgesia-and the term analgesia not anaesthesia should be used-may I most emphatically state that it does work, and it works very well. In toto, members of the delegation witnessed close to a dozen surgical procedures conducted under acupuncture analgesia. Among other procedures, we witnessed neurosurgery on both the spinal cord and the brain, thoracic surgery, a partial gastrectomy, a menisectomy and a ceasarian section. In each case, the acupuncture analgesia worked quite well.

It will not replace traditional anaesthesia as we know it here in Canadaor for that matter in China. At the present time, Chinese physicians use acupuncture analgesia in about thirty per cent of all surgical procedures.

I have no doubt that there is a place in Canadian medicine for acupuncture analgesia and this is an opinion that I know is shared by all fifteen of my colleagues who were in China.

Last June, key members of the delegation met in Ottawa to put together the final report on our visit, including some specific recommendations to a variety of agencies. Among others, we recommended to the Medical Research Council, medical schools and other research institutions that they give high priority to research on acupuncture analgesia. Hopefully, we will be able to undertake some major research on this subject here in Canada in the very near future.

At present, arrangements for the exchange of personnel are being made for Canadian anaesthetists to learn the techniques involved in China, and experienced Chinese acupuncture teachers to accept research teaching fellowships in Canada.

In short, we believe that basic research, and controlled clinical trials of acupuncture analgesia should progress simultaneously.

In recent months, the Ontario College of Physicians and Surgeons has issued a formal ruling on acupuncture for this province. In essence, the College statement reads: "The College of Physicians and Surgeons of Ontario feels that acupuncture is a medical treatment which, at this point in time, is in an experimental stage in this country. The Ontario College of Physicians and Surgeons will sanction well organized clinical trials of this therapeutic modality, and will assess the results when they are available."

During this period of assessment, the College considers acupuncture to be an experimental procedure. Physicians therefore undertaking acupuncture should obtain a fully informed, written consent from the patient which gives a description of the procedure, the results that may be expected and the possible risks involved. Furthermore, during this period of assessment, no fees shall be charged for this service.

As I was then President of the Canadian Medical Association, I commended the Ontario College of Physicians and Surgeons for taking this stand and encouraged the medical licensing bodies of other provinces to follow this lead. I do warn you and my fellow-Canadians to be extremely cautious. It is well known that unscrupulous elements in this country are at present using acupuncture on poorly informed persons. This action is just one more racket in the field of health.

With respect to acupuncture analgesia, I would propose that we go one step further. The actual utilization of acupuncture analgesia should be restricted to qualified anaesthetists during the initial research and clinical trial periods. However, on the basis of our short experience and observations, it would be my opinion that as our understanding and experience grows, there is no reason that acupuncture analgesia could not be applied by general physicians, dentists, and experienced operating room nurses, under appropriate supervision. To me it appears quite logical that in future, we should train experienced operating room nurses in the techniques involved and have them apply the actual needling-under appropriate supervision.

Incidentally, while our delegation did not include a qualified dentist to assess the value of acupuncture analgesia in dentistry, I hope that our dental colleagues will assess its potential value to their practice.

With respect to the use of acupuncture as a therapy modality, I think it is fair to say that our delegation was less impressed than we were with its use as an analgesia. The Chinese use acupuncture in the treatment of a wide variety of diseases and conditions: congenital and acquired deafness, strokes, epilepsy, Bell's palsy, schizophrenia and other mental disorders, gastric and duodenal ulcers, appendicitis, several types of liver and gall bladder disease, pancreatitis and certain female reproductive organ disorders. In the limited time that we had available, it was of course impossible for us to undertake anything in the way of a definitive study to determine whether or not such therapy was effective.

I would like to make this point especially with respect to the treatment of congenital deafness. May I emphasize that the Chinese themselves report very poor results in the treatment of children who suffer from congenital deafness. It would be misleading and cruel to congenitally deaf patients or their families to suggest that this method of treatment is effective until we have more scientifically valid evidence of its effectiveness.

I would also point out that we were singularly impressed with the quality of teaching in the school for the deaf that we visited. It is well-staffed with competent and highly motivated teachers. Several members of our delegation who had spent time in Canadian schools for the deaf indicated that the results seemed comparable to anything that they had witnessed in Canada.

The classical use of acupuncture, of course, has been for the relief of pain. Our Chinese colleagues indicated that it has proven extremely valuable in this regard-particularly in the treatment of arthritis and related disorders.

We saw a number of other things that were very impressive. For instance, the intensive care burn units in major city hospitals. We examined patients who had survived burns covering ninety-nine per cent of their bodies-with over ninety per cent having third degree burns. The Chinese attribute their extraordinary success rates to the aggressive manner in which they attack such cases. They allocate special teams of up to six or eight specially trained physicians and nurses when a patient is admitted. They conduct a radical surgical removal of burnt tissue shortly after admission to hospital, and have recently developed new techniques for both heterografts and homografts. They use very large human cadaver, pig skin-and even dog or chicken skin coverings. They frequently use two or three surgical teams for debridement purposes-and they do use both traditional Chinese medical herbs and antibiotics to control infection.

The pharmacology of traditional Chinese medicine frequently involves prescriptions of a wide range of material-sherbs, animal and mineral materials. The Chinese-as is true with acupuncture-are currently giving high priority to research programmes to determine what it is in traditional Chinese medicines that makes them effective. They are actively attempting to isolate the active ingredients and then synthesize and manufacture them. As might be expected, the manufactured, concentrated form is frequently more effective than when it is used in its natural state. It is also frequently more toxic or more frequently produces major side effects.

Several members of our delegation have expressed the opinion that it is in traditional Chinese pharmacology that we may find the most valuable contributions of Chinese medicine to other parts of the world. However, to search out these benefits will be a monumental undertaking. There are thousands of such traditional Chinese medicines, many of which have or will prove to be useless.

Several of our colleagues had special interests in the fields of medical education and medical research. They were not disappointed with this trip either.

As I have indicated, the basic concepts or dogma of medical education in China at the present time are to meld western and traditional Chinese medicine and to shorten the medical education period as much as possible. The Chinese of course are attempting to produce a new type of medical care, and to increase their physician production to offset a very serious shortage of trained medical personnel.

During the cultural revolution of the late 1960's, all medical schools, indeed all university and upper level educational programmes, were discontinued. Medical schools have only recently reopened and with considerably smaller classes.

In the early 1970's several medical schools attempted to train physicians in two years. These programmes have been declared a failure and the Chinese are now trying medical education programmes of three or three and a half years' duration. They are conducting a few research programmes whereby experienced nurses and other health workers are given special training for one to two years, in order to convert them into physicians. They report good results in this regard with the first couple of classes.

When they graduate, physicians normally return to the area- to the commune or factory-that sent them to medical school. Conversely, they may be sent to the area of the country that most urgently requires their services.

Practically all medical students have at least two years of work experience in a factory or on a commune before being admitted to medical school. They are between the ages of twenty and twenty-five, must not be married and are not allowed to marry during their educational period. In order to qualify for admission to medical school, generally speaking, an individual must be a middle school graduate-somewhat comparable to our high school graduation, have two years of work experience, then obtain clearance from the committee of the commune or factory that sent him to school.

As you are no doubt aware from newspaper reports, the delegation visited Shih-chia Chuang the gravesite of Dr. Norman Bethune. On behalf of the Canadian Medical Association, and all physicians in Canada, we paid our respects to Dr. Bethune by placing a wreath at his monument. This has been interpreted by a few as paying homage to a major shrine of Chinese communism. I emphasize-we were a medical delegation, not a political one.

The facts are, in China, Norman Bethune is revered as a national martyr. He is known by every man, woman and child of three years of age or more. While there is no place in China for religion at the present time, he is as close to a saint or an ideological model as exists in that country. For a medical delegation, the guests of the people of China, to have failed to participate in an appropriate display of respect would have been the ultimate in bad manners.

When the Chinese medical delegation visited Canada last fall, they were in Ottawa on Remembrance Day. They joined us in paying respects to the memory of Canadians who were killed in World Wars I and II. They did not ask how many of our soldiers died supporting the war efforts of Nationalist China. The late Norman Bethune, a Canadian physician, is known, revered and respected by some 800 million people of the People's Republic of China. As a Canadian medical delegation, and as the guests of the Chinese people, we acted accordingly and appropriately.

Chairman, ladies and gentlemen, it was the trip-the tour of a lifetime. I will be eternally grateful to the medical profession of Canada for having chosen me as their president, the year we went to China.

Dr. Gingras was thanked on behalf of The Empire Club of Canada by Dr. Harold V. Cranfield.